This revised proposal will address several limitations of existing programs to help hospitalized smokers, including reach and exportability. We will use the RE-AIM evaluation model to investigate an innovative intervention for reaching and involving smokers about to have out-patient surgery or an invasive endoscopic medical procedure (sigmoidoscopy/colonoscopy) in Kaiser Permanente-Colorado, but who decline to participate in cessation-based smoking activities. Based upon preliminary work and previous experience with harm reduction interventions with smokers, we will offer a harm reduction program with the goal of helping smokers achieve a 2/3 reduction in daily cigarette intake. The theory-based intervention will include goal setting and frequent feedback, barriers-based problem-solving, and other social-cognitive procedures tailored to the smoker and his or her social environment. It will be delivered both before surgery (or endoscopic procedures) and after, by a combination of phone counseling and tailored mailings, similar to that of the smoking cessation program (Project 1) proposed as part of this Interactive RO1 application. Previous work in our lab and by other investigators indicates that 50-75 percent reduction in number of cigarettes smoked is achievable and can be done in a way that does not result in compensatory smoking, so that reductions in biochemical exposures are achieved and maintained.Following a year of developmental work, we will conduct a randomized trial with 340 smokers to compare the harm reduction program to a control condition that will receive generic mailings. Following the RE-AIM model, key outcomes of the project will be 1) Reach (percent and representativeness of smokers who participate in this program); 2) Effectiveness: reductions in number of cigarettes, cotinine, and CO levels at 3 months follow-up; 3) Adoption: the percent of physicians who participate in the program; 4) Implementation: the percent of participants who receive and use each of several intervention components; and 5) Maintenance: the cessation rate, reduction in number of cigarettes and saliva cotinine, and CO levels at one-year follow-up.This is one of two projects being submitted using the Interactive Research Project Grant funding mechanism. Crossproject analyses will be conducted on various RE-AIM dimensions related to dissemination and economic outcomes. Taken together, both projects will provide an important test of an integrated program for an underserved population (patients in the hospital setting) that recognizes cessation and harm reduction as complementary strategies.